Pterional approach

• Simultaneous surgical management of a giant tuberculum sellae meningioma and pregnancy-related complications: a case report and literature review
• Childhood penetrating intracranial injury by non-metallic objects: a case report of three pediatric cases
• Exoscopic Supraorbital Keyhole Approach for Skull Base Lesions: An Institutional Experience
• Cranial-orbital approaches for vascular pathology: A review of surgical approach selection and technical considerations
• Predictors of temporalis muscle atrophy and head asymmetry following frontotemporal craniotomy: A retrospective analysis of clinical factors and volumetric comparison
• Surgical anatomy of the pterion and its relationship to the middle meningeal artery in optimizing pterional craniotomies: a cadaveric perspective
• Non-Surgical Management of Trigonocephalic Patients: An OCT and 3D-CT Based Follow-up Study
• Revisiting the combined approach of Yasargil for microsurgical removal of intra-extraventricular and pure intraventricular craniopharyngiomas

Pterional or fronto-temporal craniotomy, developed by Prof. M. G. Yasargil, is among the most familiar skull base surgery techniques ^{1) 2) 3)}.

The frontotemporal, so-called pterional, approach has evolved with the contribution of many neurosurgeons over the past century. It has stood the test of time and has been the most commonly used transcranial approach in neurosurgery. In its current form, drilling the sphenoid wingas far down as the superior orbital fissure with or without the removal of the anterior clinoid process, thinning the orbital roof, and opening the Sylvian fissure and basal cisterns are the hallmarks of this approach.

The history of neurosurgery is filled with descriptions of brave surgeons performing surgery against great odds in an attempt to improve outcomes for their patients. In the distant past, most neurosurgical procedures were limited to trephination, and this was sometimes performed for unclear reasons. Beginning in the Renaissance and accelerating through the middle and late 19th century, a greater understanding of cerebral localization, antisepsis, anesthesia, and hemostasis led to an era of great expansion in neurosurgical approaches and techniques. During this process, frontotemporal approaches were also developed and refined over time. Progress often depended on the technical advances of scientists coupled with the innovative ideas and courage of pioneering surgeons. A better understanding of this history provides insight into where we originated as a specialty and in what directions we may go in the future. In a review Ormond and Hadjipanayis consider the historical events enabling the development of neurosurgery as a specialty, and how this relates to the development of frontotemporal approaches ⁴⁾.

Pterional approach indications.

The patient should be positioned supine in a neutral position with a pad under the ipsilateral shoulder. The head should be lifted above the level of the heart to promote venous return and secured using a three-pin skull fixation device

A curvilinear skin incision is made from the superior rim of the zygomatic arch, 1 cm anterior to the tragus, to the midline just behind the hairline.

After skin incision the resulting bone flap is centered over the depression of the sphenoid ridge. Approximately 33% of the craniotomy is anterior to the anterior margin of temporalis muscle insertion, ≈ and 66% is posterior.

With the craniotome, starting at the frontal burr hole the craniotomy is taken anteriorly across the anterior margin of the superior temporal line, staying as low as possible on the orbit (to obviate having to rongeur bone, which is unsightly on the forehead).

Pterional approach soft tissue dissection.

see Pterional craniotomy.

Orbital Rim (ORo) Zygomatic Arch (ZAo) and Orbito-Zygomatic (OZo) osteotomies can be useful adjuncts to the classical Fronto-Pteriono-Temporal craniotomy in facilitating the exposure of deep seated skull base lesions, sparing brain retraction injuries.

There are different variants of the pterional approach described, such as the orbito-cranial approach as an extended and the sphenoid ridge keyhole approach as a less invasive approach ^{5) 6)}.

Pterional craniotomy complications.

Pterional approach complications.